A physician practice may think in terms of 1 patient, a family, a practice with over a thousand people. Designing systems that support the practice in terms of monitoring, tools, and team building, means thinking in blocks of 100,000 people.

A person might say,”Ted, health plans across the United States regularly do this, this is not that unique.” Well, actually it is.

AND make the tools/equipment available to get that care (from mammography machines to dexa scanners to colonoscopy suites),

AND support efficiency and sustainability of the people and careers who provide these services with care and compassion.

If you did, you would be thinking of a health system, not a health plan.

This is why, when Gail Lindsay, RN, MA, the Managing Director, Clinical Program Development for Southern California Permanente Medical Group says, “it’s a balancing act” she is making a huge understatement.

All of that said, the team here, at Regional Outreach for all of Kaiser Permanente Southern California, owns that accountability and responsibility and they carry it with them into their work.

This day was the first that I’ve heard the term “Outpatient safety,” and I love it, because I have seen the incredible amount of focus on inpatient safety, almost to the exclusion of the outpatient environment.

The problem is, if these are things that take some time to present themselves, a level of sophistication is needed beyond what most outpatient care systems have, except for here…

How much acetaminophen is that patient taking on a regular basis?

Answering the above question using most medical records, electronic or not, is difficult bordering on impossible today. Acetaminophen intake of greater than 4 grams per day is linked to liver toxicity, and in the typical doctor visit, a calculation is not going to be done about a person’s acetaminophen purchasing patterns, and in most electronic systems, this data isn’t even available.

Ruthie Goldberg talked to us about acetaminophen as an example of an outpatient safety net. The net can operate at the 3.3 million person level, doing these calculations automatically, and presenting the warning signs to physician teams, along with the precise data retrieved and dosing charts to keep acetaminophen levels in the safe range. There may be just 1-2 patients per practice where this is a concern. With this information everything from a discussion about the medication to a re-evaluation of the diagnosis can be made. See if your doctor can know this about your acetaminophen intake…

I have to point out there’s also a little bit of the Eliza flare here, as evidenced by the postcard (pictured above) sent to patients reminding them of their odds of treating colon cancer if discovered early. I am a fan of the simple, glass half-full approach.

PS Ruthie and Michael Kanter, MD, will be presenting their outpatient safety work in a number of areas in Washington, DC, in May. I’ll post details here.

Who wouldn’t want “Room Ready, Patient Ready, Computer Ready?”

This is what Kristen Andrews told us when asked about the “Why?” of the Proactive Office Encounter. What she’s describing is a level of thinking about the electronic health record integration into people’s lives that is years ahead of the rest of health care. She manages the smooth operation of POE across the 90 primary care offices in Southern California.

She also manages the expansion of the program into specialty care. We found her on the first day of piloting POE in Obstetrical care, and here, “Ready” is much more granular than ever before. The population care system is programmed to be ready on a week-by-week basis, for every patient based on their week of gestation. This allows teams to be ready for the patients from the moment of contact, not just when the physician enters the room.

She reminds us also that POE is not a computer program, either. Lamps are checked and supplies are ready, too.

“This day may be frustrating for you”

Our most awesome host, Tim Ho, MD, said this to me about today, because he knows I like to shadow at the level of the patient-physician interaction. And actually it wasn’t at all (can you tell from the length of this blog post? :))

In Tim Brown’s book for design thinkers, “Change by Design,” he says, “observation is watching what people don’t do, listening to what they don’t say,” which speaks to this, and also, in my experience, to watching what your hosts don’t do, listening to what they don’t say. With this in mind I state the preference (about being in the practice), and then let the host make the choice of where observation is best, it always works out.

Day 3 was a little bit like graduation day – the previous two days we saw components of Complete Care live – proactive office encounter, proactive panel support, proactive office support, prevention outreach, and here it was tied together for us as a system.

I would say this is exactly the way to experience Complete Care, at the level of the patient (the highest level) first, and then further “down,” to the system that supports their health.

Culture of Leadership

Speaking of glass half-full, I know that I saw a sliver of the operation of Complete Care when I was here, however, the benefit of unencumbered observation is the things people say a lot in conversation.

I heard the term “anchor” used a lot, meaning that programs need to have a home in the flow of work, and continuously supported. Diffusion is not done when something is rolled out.

I heard the term “saving lives” a lot, and I know it seems obvious that this is what people do, but I often don’t hear this mentioned explicitly in health care; it’s usually “better outcomes”, “lower cost trend.” They say the actual words – “saving lives” – here – one at a time.

I learned a ton, from Tim and the members, nurses, physicians of Kaiser Permanente Southern Calfornia and Southern California Permanente Medical Group.

When I shadow or think about environments that are not health care, I say, “as usual, I saw lots of analogies to the health care.” Here I would say,” as usual, I saw lots of the future of health care, happening today.”

Tim’s comment to us about our journey home was, “from Washington, DC to Orange County, from the exam rooms of our medical offices, we are bound together by the same goal of improving the lives of the people we serve.” It’s great that (a) activities in the exam rooms of medical offices 2,500 miles away can make an impact across the country because (b) we stop to watch and listen and (c) they stop to show and teach.

I particularly like your articulation of the primacy of health systems vs. health plans … and am reminded of Dwight D. Eisenhower's famous observation: "On the battlefield … I have always found that plans are useless, but planning is indispensable".

Joe, thanks for picking up on the language and the feeling, I visited the interview with Kathy. I agree with you that the success that is most valued is around what a person is able to do as a result of being healthy, not whether the system did it's job for them, glad this came across in my writing :),